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Correction of Severe Crouch Gait in Patients with Spastic Diplegia with

Use of Multilevel Orthopaedic Surgery
J.M. Rodda, H.K. Graham, G.R. Nattrass, M.P. Galea, R. Baker and R. Wolfe
J Bone Joint Surg Am. 2006;88:2653-2664. doi:10.2106/JBJS.E.00993

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Correction of Severe Crouch

Gait in Patients with
Spastic Diplegia with Use of
Multilevel Orthopaedic Surgery
BY J.M. RODDA, PHD, H.K. GRAHAM, MD, FRCS(ED), FRACS, G.R. NATTRASS, MD, FRCS(C), FRACS,
M.P. GALEA, PHD, R. BAKER, PHD, CENG, AND R. WOLFE, PHD
Investigation performed at The Royal Children’s Hospital, Melbourne, Australia

Background: Severe crouch gait in patients with spastic diplegia causes excessive loading of the patellofemoral
joint and may result in anterior knee pain, gait deterioration, and progressive loss of function. Multilevel orthopaedic
surgery has been used to correct severe crouch gait, but no cohort studies or long-term results have been reported,
to our knowledge.
Methods: In order to be eligible for the present retrospective cohort study, a patient had to have a severe crouch
gait, as defined by sagittal plane kinematic data, that had been treated with multilevel orthopaedic surgery as well as
a complete clinical, radiographic, and instrumented gait analysis assessment. The surgical intervention consisted of
lengthening of contracted muscle-tendon units and correction of osseous deformities, followed by the use of ground-
reaction ankle-foot orthoses until stable biomechanical realignment of the lower limbs during gait was achieved. Out-
come at one and five years after surgery was determined with use of selected sagittal plane kinematic and kinetic pa-
rameters and valid and reliable scales of functional mobility. Knee pain was recorded with use of a Likert scale, and
all patients had radiographic examination of the knees.
Results: Ten subjects with severe crouch gait and a mean age of 12.0 years at the time of surgery were studied. Af-
ter surgery, the patients walked in a more extended posture, with increased extension at the hip and knee and re-
duced dorsiflexion at the ankle. Pelvic tilt increased, and normalized walking speed was unaltered. Knee pain was
diminished, and patellar fractures and avulsion injuries healed. Improvements in functional mobility were found, and,
at the time of the five-year follow-up, fewer patients required the use of wheelchairs or crutches in the community
than had been the case prior to intervention.
Conclusions: Multilevel orthopaedic surgery for older children and adolescents with severe crouch gait is effective
for relieving stress on the knee extensor mechanism, reducing knee pain, and improving function and independence.
Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

C
rouch gait is a term that is frequently used generically gravity support muscles. Failure of the total body extensor mo-
to describe a gait pattern characterized by increased ment as a result of diminished ability of the hip, knee, or ankle
knee flexion in the stance phase of the gait cycle, espe- plantar flexor moments may result in collapse of the extension
cially in individuals with spastic diplegic cerebral palsy1-8. Bi- posture into a flexion posture, described as crouch gait (Fig.
pedal gait has evolved to be energy-efficient by keeping the 1). This often occurs as part of the natural history of gait in
foot reasonably close to plantigrade position during stance, patients with cerebral palsy10-12 but may be precipitated by any
while adopting a relatively extended posture at the hip and intervention that weakens the gastrocnemius-soleus muscle.
knee. The body is maintained in this upright, extension pos- Such interventions may include injection of Botulinum toxin A
ture by the action of three main muscle groups: the hip exten- (Botox), selective dorsal rhizotomy9,13, and surgical lengthening
sors, the knee extensors, and the ankle plantar flexors9. The of the triceps surae as treatment for equinus deformity7,14-16.
ground-reaction force is maintained close to the centers of the In patients with spastic diplegia, there is usually weak-
hip, knee, and ankle joints, reducing the demands on the anti- ness in the three major groups of muscles responsible for re-
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sisting the tendency toward the development of a crouch gait, Standing with >30° of knee flexion increases the forces acting
but the majority of younger individuals walk with a reason- on the quadriceps, patella, and proximal part of the tibia and
ably upright posture in early childhood17. Progressive crouch requires the quadriceps muscle to work at >50% of its maxi-
gait often develops rapidly around the time of the pubertal mum moment-generating capacity in order to stabilize the
growth spurt9. Proposed explanations are the inherent lower knee joint23. Progressive failure of the knee extensor mecha-
limb weakness associated with spastic diplegic cerebral palsy, nism is associated with gait deterioration, increased depen-
the development of an unfavorable body mass-to-strength ra- dence on walkers or crutches, and the need for wheelchair use
tio, and the development of musculoskeletal deformities, col- in the community.
lectively referred to as lever arm deformities9. The antigravity Given that the cause of crouch gait is usually multifac-
support muscles must resist the external moments imposed by torial and difficult to characterize precisely, treatment is contro-
gravity by generating internal moments acting on the hip, knee, versial24. Options include muscle-strengthening16,25, external
and ankle joint centers. If the femora or tibiae are malaligned support with orthoses9, and orthopaedic operations to correct
and the hip joint or midfoot is unstable, the moment-generating fixed musculoskeletal deformities at single or multiple levels9.
capability of the muscle-tendon units may be diminished, The choice of orthopaedic procedures may be based on clinical
contributing to the crouch position18. The deformities (termed evaluation alone, but instrumented gait analysis is increasingly
lever arm deformities) that are frequently seen in adolescents recommended to aid decision-making. There is also an increas-
with spastic diplegia are excessive femoral anteversion, hip ing trend to correct as many musculoskeletal deformities as pos-
subluxation, patella alta, excessive external tibial torsion, and sible in one operative session, variously described as multilevel
pes valgus9,19,20. surgery, multiple lower extremity procedures, or single-event
Once the crouch gait reaches a certain level of severity in multilevel surgery9,26-30. The evidence base for the effectiveness of
the child, the degree of knee flexion and associated symptoms orthopaedic surgery to correct crouch gait in patients with spas-
may progress rapidly because of high stresses at the knee and tic diplegia is poor. A number of single case reports9 and small
failure of the knee extensor mechanism6. Knee pain16, patella case series that include many different gait patterns26-30 have been
alta, and fragmentation or fracture of the inferior pole of the published, but no cohort studies with adequate follow-up and
patella all have been documented in this clinical setting6,21,22. no clinical trials have been reported, to our knowledge. In addi-

Fig. 1
Crouch gait is characterized by excessive ankle dorsi-
flexion, excessive knee flexion, increased hip flexion,
and variable pelvic position (left). The ground-reaction
force (shown as the vertical arrow) is directed posterior
to the center of the knee joint and anterior to the hip
joint. The three main muscle groups that contribute to
the total body extensor moment are (1) the hip exten-
sors, (2) the knee extensors, and (3) the ankle plantar
flexors. In severe crouch gait, these muscles are weak
and may be excessively long. Habitual standing and
walking in flexion, combined with spasticity, may result
in contractures of the iliopsoas (4) and the hamstrings
(5). The principles for the correction of crouch gait may
include lengthening of contracted muscle-tendon units
(4 and 5) and support of long and weak muscle-tendon
units (1, 2, and 3) in an extended position using a
ground-reaction ankle-foot orthosis with the ground-
reaction force (vertical arrow) now directed in front of
the center of the knee joint (right).
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tion, inconsistent definitions of the term crouch gait1-6,8,17,25,31-36 pist (J.M.R.). The soft-tissue surgical procedures were intra-
and the failure to define gait patterns quantitatively further muscular lengthening of the psoas muscle at the pelvic brim39,
weakens the evidence base used to address this issue. percutaneous lengthening of the adductor longus, fractional
To our knowledge, this is the first study that documents lengthening of the medial and/or lateral hamstrings40, and
the intermediate-term outcome of multilevel orthopaedic sur- transfer of the rectus femoris to the semitendinosus41. The os-
gery combined with the use of orthoses and a rehabilitation seous procedures for the correction of lever arm deformities
program for the treatment of severe crouch gait in patients were external rotation osteotomy of the femur42-45, internal ro-
with spastic diplegic cerebral palsy. The key features of this co- tation osteotomy of the distal parts of the tibia and fibula19,20,46,
hort study were the utilization of a precise definition for se- calcaneal lengthening19,47, and subtalar fusion19,48. Stable inter-
vere crouch gait and the application of a balanced raft of nal fixation was used routinely to permit early weight-bearing.
objective outcome measures at one and five years after surgery. A first-generation cephalosporin was given at the time of in-
The purposes of the present study were to evaluate the func- duction of anesthesia and was continued for twenty-four
tional and technical outcomes of single-event multilevel sur- hours postoperatively. In all patients, analgesia was adminis-
gery on severe crouch gait at one year after surgery and to see tered by means of continuous epidural infusion of bupiv-
if benefits observed at one year postoperatively were main- acaine and fentanyl for three to five days after surgery.
tained at five years. After foot and ankle surgery, postoperative immobiliza-
tion was achieved with use of padded, split, below-the-knee
Materials and Methods plaster casts, with knee immobilizers being used to maintain
Subjects knee extension. Physical therapy began with the epidural infu-
his retrospective cohort study was conducted in a chil- sion in place and consisted of passive and active joint move-
T dren’s tertiary care hospital between 1995 and 2004. The
granting of approval for clinical audit of these data complied
ment. Plaster casts were removed to permit wound inspection
and radiographs of the osteotomy sites at three weeks after
with the ethical requirements of the Ethics in Human Re- surgery, followed by the application of fiberglass below-the-
search Committee at our institution. All data were gathered knee casts. If there was satisfactory healing at the wound and
prospectively in accordance with established gait laboratory osteotomy sites, weight-bearing was encouraged at that time.
protocols, but the identification of the cohort and analysis of The casts were removed six weeks after surgery and proximal
the data were retrospective. rear-entry, ground-reaction, ankle-foot orthoses were fitted.
The subjects were a consecutive sample of patients, rang- Radiographs of all osteotomy sites were made, and full weight-
ing from four to eighteen years old, who had spastic diplegic bearing was encouraged when healing at the osteotomy sites
cerebral palsy and walked with a severe crouch gait, either inde- was demonstrated. Knee immobilizers were used continuously
pendently or with the use of assistive devices (walkers, crutches, for the first six weeks and at night only for another six months
or walking sticks). All subjects were classified as level II or III ac- to reduce the risk of recurrent knee contractures. The knee
cording to the Gross Motor Function Classification System immobilizers were removed for therapy and were replaced at
with use of the nearest age-appropriate descriptor37. Severe the end of therapy sessions.
crouch gait was defined according to sagittal plane kinematic All patients were managed with an individually tai-
data, collected during barefoot walking, as ankle dorsiflexion of lored, community-based rehabilitation program that initially
>15°, knee flexion of >30°38, and hip extension of <3° during incorporated three or four sessions of physical therapy and
late stance phase. These parameters were all outside the normal one or two sessions of hydrotherapy per week, starting six
range for our laboratory and fulfilled the knee flexion defini- weeks after surgery (at the time of cast removal) and continu-
tion for severe crouch gait proposed by Sutherland and ing for twelve weeks. The children gradually were advanced
Davids38. In this cohort, severe crouch gait was invariably from a passive to an assisted range-of-motion protocol and fi-
symptomatic and in most patients was documented to be nally to a resistance program. The frequency of physical ther-
progressive on the basis of serial examination and gait labo- apy sessions was reduced to one per week after six months,
ratory assessment. and the subjects were encouraged to participate also in physi-
Exclusion criteria were previous selective dorsal rhizot- cal recreational activities such as bicycle riding, swimming,
omy, use of an intrathecal Baclofen pump, or Botulinum toxin horseback riding, and/or a program at a local gymnasium.
A injections within the preceding twelve months. Formal physical therapy stopped after one to two years, al-
though some subjects chose to continue with unstructured ac-
Intervention: Multilevel Orthopaedic tivities such as swimming, bicycle riding, or weight-training.
Surgery, Ground-Reaction All patients were reviewed in the gait laboratory at three,
Ankle-Foot-Orthoses, and Rehabilitation six, and nine months after surgery with use of a combination
All patients were offered a combined surgical, orthotic, and of standardized clinical examination and two-dimensional
rehabilitation program for the treatment of severe crouch gait. video recording of gait. The purpose was to allow close moni-
The surgical recommendations were determined with use of a toring of the rehabilitation process and to make appropriate
comprehensive gait laboratory assessment by the two treating changes to orthoses, assistive devices, and the physical therapy
orthopaedic surgeons (H.K.G. and G.R.N.) and a physiothera- program to optimize each subject’s rehabilitation process. The
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TABLE I Demographic Characteristics, Previous Surgery, and Surgical Recommendations for Each Subject ➤

Gross Motor
Function Age at Single- Adductor
Classification Event Multilevel Psoas Longus
Case Gender System Previous Surgery Surgery (yr) Over Brim Lengthening
1 M III Baker calf lengthening 10.3
2 M III Tendo-achilles lengthening × 2 12.8 Bilateral Bilateral
3 M III None 13.3 Bilateral

4 F III Baker calf lengthening 14.2 Bilateral Bilateral

5 M III Tendo-achilles lengthening 10.9

6 M III Tendo-achilles lengthening 10.7

7 M II Tendo-achilles lengthening 12.4

8 F III Tendo-achilles lengthening 11.4

9 F II Botox injection, calves 7.9 Bilateral

10 M II Tendo-achilles lengthening 16.2

Mean (range) 12.0 (7.9 to 16.2)
Total no. of 8 4
procedures

ankle-foot orthoses were prescribed to be worn during all lateral radiographs of both knees before surgery and at the
weight-bearing activities for the first twelve months after sur- twelve-month and five-year assessments. The Insall-Salvati
gery, at which time the need for ongoing orthotic support was ratio50-52 was measured on a lateral radiograph of the knee,
assessed with use of gait analysis. Only one subject continued made with the knee in 20° to 40° of flexion. The contrast and
to use the orthoses after twelve months. Between twelve and brightness were adjusted before printing to enhance the defini-
twenty-four months after surgery, eight patients had removal tion of the soft tissues, with particular reference to the patellar
of implants and three had surgery for the treatment of ingrown tendon and the cartilaginous portion of the tibial tuberosity.
toenails, but no additional surgery was performed for the treat- Patellar length was measured from the proximal pole to the
ment of contractures. All patients had a comprehensive evalua- distal pole, irrespective of patellar fractures or avulsions. Patel-
tion in the gait laboratory at one and five years after surgery. lar tendon length was measured from the inferior pole of the
patella to the maximum convexity of the tibial tuberosity. The
Outcome Measures: Physical Examination, Insall-Salvati ratio was calculated by dividing the length of the
Pain Scale, Knee Radiographs, patellar tendon by the patellar length. Patella alta was consid-
Gait Analysis, and Functional Scales ered to be present when the ratio was greater than the normal
A standardized physical examination was conducted as part of range for the subject’s age according to previously published
the preoperative gait analysis and at the twelve-month and reference data52. In addition, the presence of avulsion injury to
five-year assessments. The findings were recorded on a gait the inferior pole of the patella or the presence of patellar frac-
laboratory data sheet and included measurements of joint tures was noted, including evidence of healing.
contractures, muscle strength, spasticity, selective motor con- A Vicon 370 System (Oxford Metrics, Oxford, England)
trol, and osseous rotational abnormality. The parameters di- with five infrared cameras was used for the three-dimensional
rectly relevant to the present study included measurement of gait analyses. The walkway incorporated two force-plates
fixed flexion deformity at the hip and knee, measurement of (Advanced Mechanical Technology, Watertown, Massachu-
hamstring contracture as demonstrated by the popliteal angle, setts). Marker placement was performed as described in the
and measurement of gastrocnemius and soleus length with Vicon Clinical Manager manual with the Knee Alignment
use of the Silfverskiold test. The test protocol and reliability Device used during the static trial53. The subject was asked to
have been reported elsewhere49. walk barefoot using the usual gait pattern, at a self-selected
Because of the high prevalence of knee pain in this popu- speed, along a 10-m walkway in the gait laboratory. If the
lation, all patients were evaluated on the basis of a pain score subject usually used an assistive device in order to walk, then
according to a 9-point Likert scale as well as anteroposterior and this device was used during the walking trials. All data were
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TABLE I (continued)

Single-Event Multilevel Surgery

Medial Hamstrings Lateral Hamstrings Rectus Femoris Femoral Tibial Number of
Fractional Fractional Transfer to Derotation Derotation Surgical
Lengthening Lengthening Semitendinosus Osteotomy Osteotomy Foot Surgery Procedures
Bilateral Bilateral Unilateral 7
Bilateral Unilateral distal 7
Bilateral Bilateral os calcis 6
lengthening
Bilateral Unilateral distal 5
Bilateral Bilateral Unilateral distal Unilateral Unilateral subtalar 7
joint fusion
Bilateral Bilateral Bilateral distal Bilateral subtalar 8
joint fusion
Bilateral Bilateral Bilateral Bilateral distal 8

Bilateral Bilateral Bilateral 8

Bilateral Bilateral Bilateral 6
Bilateral Bilateral Bilateral Bilateral proximal 8
7 (5 to 8)
20 12 8 9 4 5

processed with use of PIG (Plug-in Gait) software. Once pro- Statistical Analysis
cessed, three to six trials were then scrutinized, from which To compare mean outcomes for the severe crouch group at
a typical representative trial for the left and right sides was baseline, one year, and five years, linear regression models
chosen for analysis. Selected temporospatial, kinematic, and with robust standard errors61 to allow for the repeated mea-
kinetic parameters were analyzed for the purposes of this surements from individual patients over time were used62.
study, including normalized velocity54-57, mean pelvic tilt, Data from both limbs of each of the ten subjects were included
maximum hip extension in stance, knee extension at initial in the statistical analysis as the robust standard errors are in-
contact, maximum knee extension in stance, knee flexor mo- flated to take into account any excess correlation in measure-
ment in stance, dorsiflexion at initial contact, maximum dorsi- ments from the two limbs from the same subject62. P values
flexion in stance, and maximum ankle power generation and 95% confidence intervals of the estimated difference in
prior to toe-off. Gait data from the study cohort were com- means were obtained. Parameters that were analyzed with use
pared with those for a subgroup of fourteen children with- of this method were temporospatial parameters, physical ex-
out abnormality who were comparable to the study cohort in amination findings, and kinematic and kinetic variables.
terms of demographic characteristics. A senior physiothera- Comparisons of mobility status over time were described by
pist (J.M.R.) completed all data collection except for the ra- odds ratios calculated from ordered logistic regression with
diographic data and pain scores, which were collected by a robust standard errors. Statistical analysis was performed with
surgeon (H.K.G.). use of the Stata 7 software package61 and was overseen by a se-
We used three valid and reliable instruments to measure nior biomedical statistician (R.W.). The level of significance
functional mobility: the Gross Motor Function Classification was set at p < 0.05.
System37, the Functional Mobility Scale58, and the Functional
Assessment Questionnaire59. The Gross Motor Function Clas- Results
sification System is best considered as a tool to stratify patients Subjects
with cerebral palsy according to broad functional levels. It is en subjects fulfilled eligibility criteria within the ten-year
considered to be stable over time60, is not responsive to inter-
vention, and is not usually used as an outcome measure. In
T study period. Four additional patients with severe crouch
gait were unable to attend the gait laboratory to complete all
contrast, the Functional Mobility Scale and the Functional As- assessments within the follow-up period or had not been fol-
sessment Questionnaire are sensitive to change in the cerebral lowed for at least five years postoperatively. The study group
palsy population and are both used as outcome measures after included seven male and three female patients with a mean
orthopaedic surgery. age of 12.0 years (range, 7.9 to 16.2 years) at the time of sur-
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gery. Eight of the ten subjects had had previous surgery to The fourteen subjects without abnormality who com-
lengthen the gastrocnemius-soleus, including six who had had prised a comparison group included five boys and nine girls
bilateral lengthening of the Achilles tendon and two who had with a mean age of 11.9 years (range, 7.5 to 14.9 years).
had a bilateral Baker procedure to lengthen the gastrocnemius
aponeurosis and soleus fascia. One subject had received re- Clinical Examination
peated injections of Botulinum toxin A (Table I). Hip flexion contracture as assessed with the Thomas test de-
The surgical procedures for each subject are documented creased from a mean of 21° preoperatively to a mean of 13° at
in Table I. There were eighteen osseous procedures and fifty- twelve months postoperatively and 9° at five years postopera-
two soft-tissue procedures. There were no delayed unions, mal- tively (Table II). Fixed flexion deformity at the knee improved
unions, or deep infections. Ten surgical complications occurred from a mean of 17° preoperatively to a mean of 6° at one and
in four patients, including superficial wound infection at the five years postoperatively. There was a corresponding decrease
sites of four incisions and partial separation at the sites of two in the popliteal angle. Passive ankle dorsiflexion with the knee
hamstring incisions. All resolved with a combination of oral flexed decreased from a mean of 23° preoperatively to a mean
antibiotics and wound care. Two patients with knee flexion de- of 16° at five years postoperatively. Passive ankle dorsiflexion
formities of 22° and 28° had paresthesias in the distribution of with the knee extended decreased from a mean of 3° at base-
the common peroneal nerve, without motor signs. Paresthetic line to 1° at five years, but this change was not significant.
pain was treated by removing the knee immobilizers, reducing
the degree of knee extension, and gradually extending the af- Temporal-Spatial Data
fected knee over two to three weeks. One patient had persis- Normalized speed did not change and remained decreased
tent foot pain after calcaneal lengthening that had features of a compared with normal data (Table II).
type-II complex regional pain syndrome. This patient was
managed with continuation of weight-bearing and administra- Kinematic Data
tion of oral gabapentin for six weeks. These complications re- Kinematic data were collected at baseline, twelve months, and
solved without operative intervention but caused some delay in five years for all subjects (Fig. 2). Mean pelvic tilt increased
full weight-bearing and mobilization. from 14° to 28° at twelve months and recovered slightly to 24°
The mean increase in height was 7 cm at twelve months at five years after surgery (Table II). Two subjects had posterior
and 20 cm at five years. The mean increase in weight was 7 kg pelvic tilt at baseline but had anterior pelvic tilt after surgery.
at twelve months and 15 kg at five years. Although there was a decrease in hip flexion contracture, there

TABLE II Selected Physical Examination, Temporal-Spatial, Kinematic, and Kinetic Data Before Surgery and One and Five Years
After Surgery, Compared with Normal Values*

Surgical Status
1 Year 5 Years
Parameter Preop. Postop. Postop. Normal
Fixed flexion deformity, hip (deg) 21 ± 11 13 ± 8† 9 ± 5‡ 0±0
Fixed flexion deformity, knee (deg) 17 ± 8 6 ± 7† 6 ± 7‡ 1±2
Popliteal angle (deg) 70 ± 16 56 ± 15† 55 ± 13 39 ± 12
Ankle dorsiflexion (knee flexion) (deg) 23 ± 11 22 ± 11 16 ± 13 23 ± 7
Ankle dorsiflexion (knee extension) (deg) 3±6 2±8 1±7 5±4
Normalized velocity 0.02 ± 0.006 0.02 ± 0.008 0.02 ± 0.008 0.03 ± 0.004
Mean pelvic tilt (deg) 14 ± 12 28 ± 9† 24 ± 9‡ 13 ± 4
Maximum hip extension, stance phase (deg) 17 ± 16 16 ± 12 14 ± 11 –8 ± 5
Knee extension, initial contact (deg) 52 ± 7 25 ± 9† 26 ± 10‡ 7±5
Maximum knee extension, stance phase (deg) 44 ± 9 13 ± 9† 17 ± 11‡ 5±4
Maximum knee flexor moment (N m/kg) 0.3 ± 0.2 –0.4 ± 0.3† –0.2 ± 0.2‡ –0.2 ± 0.2
Ankle dorsiflexion, initial contact (deg) 12 ± 10 3 ± 9† 0 ± 6‡ –1 ± 3
Maximum ankle dorsiflexion, stance phase (deg) 29 ± 9 17 ± 8† 15 ± 6‡ 15 ± 4
Maximum ankle power generation, late stance 1.2 ± 0.6 1.4 ± 0.6 1.8 ± 0.4‡ 4.2 ± 0.8
phase (W/kg)

*The values are given as the mean and the standard deviation. †The value at one year postoperatively was significantly different from the
preoperative value (p <0.05). ‡The value at five years postoperatively was significantly different from the preoperative value (p < 0.05).
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was not a significant improvement in hip extension during Kinetic Data

stance phase. Knee extension at initial contact and maximum Kinetic data could only be collected for seven subjects at base-
extension in stance phase improved significantly, with a slight line, for four subjects at one year, and for five subjects at five
deterioration at five years compared with twelve months (95% years. The excessive knee flexor moment decreased after surgery
confidence interval, 0.3° to 7.4°) (p = 0.03) (Table II). At the (Table II). There was a 50% increase in ankle power generation
ankle level, excessive dorsiflexion at initial contact and maxi- at toe-off at five years, but this was still only approximately 40%
mum dorsiflexion during stance phase decreased after surgery. of the normal value (Table II).
The mean baseline hip rotation during stance phase for
the subjects with severe crouch gait was 10° ± 11° of internal Function
rotation, which was significantly increased compared with Improvements were seen in all three mobility scales, including
the value for normally developing subjects, who had a mean the Gross Motor Function Classification System, which is not
of 2° ± 6° of internal rotation (p < 0.003). At one year post- considered to be responsive to change (Fig. 3). There was no
operatively, the value for the subjects with severe crouch gait change in the Gross Motor Function Classification System at
improved to 2° ± 10° of external rotation, indicating some one year after surgery, but at five years two subjects had im-
overcorrection at the site of the femoral derotation osteoto- proved by one level, from level III to level II, meaning that
mies. At five years postoperatively, the value for these subjects they no longer required assistive devices to walk in the com-
was 6° ± 10° of internal rotation; this was still an improve- munity. Improvements in the three subscales of the Func-
ment compared with the baseline value, but the difference tional Mobility Scale are detailed in Figure 3. Compared with
was not significant. the baseline value, the odds were four times greater (95% con-

Fig. 2
Sagittal plane kinematic graphs for normal subjects and the subjects with severe crouch gait at baseline and
at one and five years after surgery. The vertical axis of each graph is angular displacement in degrees, and the
horizontal axis of each graph is the phase of the gait cycle, with the vertical lines indicating “toe-off.” The thick
black line indicates the mean kinematic value for the severe crouch cohort, with the dotted lines and shaded
areas corresponding to one standard deviation about the mean. From top to bottom, the graphs show sagittal
plane kinematics of pelvic tilt, hip flexion, knee flexion, and ankle dorsiflexion.
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TABLE III Maximum Knee Extension in Stance Phase Prior to Single Event Multilevel Surgery, Knee Pain, Insall-Salvati
Ratio, and Knee Radiographic Findings Before and After Surgery ➤

Preop. Maximum
Knee Extension (deg) Knee Pain Score (points)
Case Right Left Preop. 1 Yr Postop. 5 Yr Postop.
1 56 34 2 0 1
2 41 49 8 0 2
3 41 37 6 0 1

4 54 49 3 2 3
5 43 44 4 0 0

6 58 60 6 0 1

7 35 43 4 0 0

8 41 46 5 1 —
9 46 46 2 0 0
10 31 31 4 0 1

Mean and standard deviation‡ 45 ± 9 44 ± 8 4.4 0.3 1

P value§ NA <0.001 <0.001
Estimated difference in means –4.1 (–5.7 to –2.5) –3.4 (–4.8 to –2.0)
(and 95% confidence interval)

*Insall-Salvati ratio above the mean according to age. †Insall-Salvati ratio more than two standard deviations above the mean according to
age. ‡Only the mean value is given for the knee pain score. §NA = not applicable.

fidence interval, 1.2 to 12.0 times greater) that a subject would surgery, with no change in the Insall-Salvati ratio (95% confi-
have a rating of 5 or 6 (rather than 4 or less) at five years on dence interval, –0.018 to 0.026) (p = 0.7) (Table III).
the 500-m scale. At five years after surgery, more patients were
walking independently, with reduced dependence on wheel- Discussion
chairs, for distances of >500m. Median Functional Assessment rouch gait is often used to describe any gait pattern associ-
Questionnaire scores increased at twelve months and five
years after surgery. One year postoperatively, the number of
C ated with spastic diplegia in which there is excessive knee
flexion during stance phase1-6,8,17,25,31-36. However, there are at least
subjects decreased at levels 5, 6, and 7 and increased at level 8. three flexed-knee gait patterns in spastic diplegia that are associ-
Compared with baseline, this represented threefold greater ated with three different ankle alignments: calcaneus, planti-
odds (95% confidence interval, 1.0 to 7.9-fold greater odds) of grade, and equinus63. These three flexed-knee subgroups are
a rating of 8 or higher rather than 7 or lower (Fig. 3). biomechanically and clinically distinct and may require differ-
ent management strategies63,64. Sutherland and Davids38 were the
Knee Pain and Radiology first to define crouch gait quantitatively (>30° of knee flexion
All patellar avulsions and fractures were noted to have healed throughout stance) and to specify excessive ankle dorsiflexion. In
on follow-up radiographs (Figs. 4-A and 4-B), with the excep- the present study, we used the qualitative description proposed
tion of two in one patient. One subject had stable, pain-free fi- by Frost2 for crouch gait, which is calcaneus at the ankle with ex-
brous union of a bilateral patellar fracture. There was a large cessive flexion at the knee and hip (Fig. 1), and developed a
reduction in knee pain scores (95% confidence interval, −4.8 quantitative definition for severe crouch gait on the basis of sag-
to −2.0) (p < 0.001) (Table III). ittal plane kinematic criteria. These are an extension of the crite-
In nine patients the Insall-Salvati ratio was increased ria proposed by Sutherland and Davids38. This definition is
above the mean for age-matched subjects, and in seven pa- proposed because crouch gait of this severity is invariably symp-
tients it was more than two standard deviations above the tomatic, progressive, and may not be sustainable17. The majority
mean for age-matched subjects. The prevalence of patella alta of patients have knee pain and radiographic evidence of failure
was very high before surgery but remained unchanged after of the knee extensor mechanism (Table III, Figs. 4-A and 4-B).
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TABLE III (continued)

Insall-Salvati Ratio
Preop. Postop. Radiographic Findings in Knee
Normal Values
Right Left Right Left According to Age52 Preop. Postop.
1.69* 1.63* 1.74† 1.66* 1.0 to 1.7 Patella alta Patella alta
1.07 1.10 1.05 1.11 0.9 to 1.3 Fractures Fibrous union
1.64† 1.56† 1.56† 1.57† 0.8 to 1.3 Patella alta, Patella alta,
fractures fractures healed
1.45† 1.40† 1.49† 1.41† 0.8 to 1.3 Patella alta Patella alta
1.84† 2.00† 1.91† 2.00† 1.1 to 1.5 Patella alta, Patella alta,
avulsions avulsions healed
1.44* 1.53† 1.45* 1.48* 1.1 to 1.5 Patella alta, Patella alta,
fractures fractures healed
1.73* 1.98† 1.76† 2.00† 0.9 to 1.3 Patella alta, Patella alta,
fractures fractures healed
1.20* 1.24* 1.25* 1.23* 0.9 to 1.3 Patella alta Patella alta
1.35* 1.54* 1.40* 1.49* 1.0 to 1.7 Patella alta Patella alta
1.55† 1.57† 1.51† 1.52† 0.8 to 1.2 Patella alta, Patella alta,
avulsions avulsions healed
1.5 ± 0.3 1.5 ± 0.3
NA 0.7
0.004 (–0.018 to 0.026)

In the present study, lengthening of the psoas at the pel- We relied on long-term use of ground-reaction ankle-
vic brim and lengthening of the hamstrings were only partially foot orthoses to support an extension posture after surgery in
successful for the correction of hip and knee-flexion contrac- the hope that the excessively long quadriceps and soleus
ture. Some patients had a minor hip flexion contracture and would adaptively shorten as the femur and tibia continued to
on kinematic evaluation had a posterior pelvic tilt. Despite grow9. This may have happened to a useful degree in some pa-
these findings, the pelvis became anteriorly tilted after ham- tients. Excessive ankle dorsiflexion decreased, and calf power
string lengthening. According to contemporary criteria4,32,33, generation increased. A decrease in quadriceps lag was noted
we performed too few psoas lengthenings and too many ham- but was not quantified. However, there was kinematic evi-
string procedures. This resulted in good improvements at the dence of much improved knee extension. We think that the
knee level but much smaller improvements at the hip level and shortening of the extensor mechanism may have occurred in
an increase in anterior pelvic tilt as the femur became more the quadriceps muscle because the patellar tendon length, as
vertically aligned. determined with the Insall-Salvati ratio, was unchanged after
A substantial proportion of hip extensor torque comes surgery. Acute shortening of the extensor mechanism through
from the proximal hamstrings65. Distal hamstring lengthen- patellar tendon-shortening surgery would be an alternative to
ing resulted in improvements at the knee but increased ante- slow, adaptive shortening, which is dependent on compliance
rior pelvic tilt, a finding noted in previous studies66-70. with the use of ankle-foot orthoses. Patellar tendon shorten-
Hamstring lengthening is not the only method available for ing9,81-87 combined with supracondylar extension osteotomy of
the correction of a knee flexion deformity and may not be the the femur has been used more recently9,79. No long-term re-
most efficient method for correcting a knee flexion deformity sults of these procedures have been reported79.
in patients with a crouch gait associated with cerebral palsy. The most important gain from the treatment method
Alternatives include transfer of one or more of the hamstring used in our patients was increased function and independence
tendons to the femur71-76 or extension osteotomy of the distal in the community. The Gross Motor Function Classification
part of the femur9,77-80. However, there have been few reports System is considered to be stable over time, yet two patients im-
to support the use of these alternative procedures. proved from level III to level II, meaning that they no longer re-
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ticularly if there is a crouch gait. Five years after surgery, the

majority of the patients in our study had gone through pu-
berty and had reached or were close to skeletal maturity, with
improved gait and function.
Issues for further investigation include increased efforts
to prevent progressive crouch gait by the avoidance of inter-
ventions that weaken the gastrocnemius-soleus, attempts to
delay progression with use of orthotic support, and a search
for more efficient surgical management.
In conclusion, a combined program of multilevel ortho-
paedic surgery, orthotic support, and rehabilitation for chil-
dren and adolescents with spastic diplegic cerebral palsy and
severe crouch gait resulted in relief of knee pain, increased ex-
tension during gait, and improved ability to function in the
community. Improvements in dynamic knee, ankle, and hip
function were accompanied by increased anterior pelvic tilt.
The improvements that were noted at one year were largely
maintained at five years.

Fig. 3
Graphs illustrating changes in the mobility scales, including the Gross
Motor Function Classification System (GMFCS), Functional Mobility
Scale (FMS), and Functional Assessment Questionnaire (FAQ), from
preoperatively to one year and five years postoperatively.

quired the use of assistive devices in the community. The

Functional Mobility Scale over 500m confirmed similar im-
provements. Prior to surgery, the majority of the severe crouch
subjects were rated as “limited community ambulators” on the
Functional Assessment Questionnaire59, but by five years the
majority were rated as “community ambulators” (Fig. 3).
The present study had a number of limitations, includ- Fig. 4-A Fig. 4-B

ing a small sample size, retrospective data analysis, lack of Figs. 4-A and 4-B Case 2. Fig. 4-A Lateral radiograph of the knee,
controls, and variable surgical prescription. Despite our pre- showing fracture separation of the patella at the time of surgery for se-
cise definition of severe crouch gait, there was still consider- vere crouch gait, which included distal hamstring lengthening and distal
able heterogeneity within the study cohort and variability in femoral derotation osteotomy with plate fixation. Fig. 4-B Five years af-
outcome. The natural history of gait in patients with cerebral ter surgery, the distal femoral osteotomy site has united, the patellar
palsy is deterioration of walking ability with time10-12,88,89, par- fracture has healed with fibrous union, and patella alta persists.
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Appendix M.P. Galea, PhD

Additional information and illustrations of the Gross School of Physiotherapy, University of Melbourne, Parkville 3010, Victo-
Motor Function Classification System (GMFCS) and the ria, Australia
Functional Mobility Scale (FMS) are available with the elec- R. Wolfe, PhD
tronic versions of this article, on our web site at jbjs.org (go to Department of Epidemiology and Preventive Medicine, Monash Univer-
the article citation and click on “Supplementary Material”) sity, Commercial Road, Melbourne 3004, Victoria, Australia
and on our quarterly CD-ROM (call our subscription depart-
ment, at 781-449-9780, to order the CD-ROM). „ In support of their research for or preparation of this manuscript, one or
more of the authors received grants or outside funding from a National
Health and Medical Research Council, Clinical Centre of Research Excellence
grant. None of the authors received payments or other benefits or a commit-
J.M. Rodda, PhD ment or agreement to provide such benefits from a commercial entity. No
H.K. Graham, MD, FRCS(Ed), FRACS commercial entity paid or directed, or agreed to pay or direct, any benefits to
G.R. Nattrass, MD, FRCS(C), FRACS any research fund, foundation, educational institution, or other charitable or
R. Baker, PhD, CEng nonprofit organization with which the authors are affiliated or associated.
Hugh Williamson Gait Laboratory, University of Melbourne, Royal Chil-
dren’s Hospital, Flemington Road, Parkville 3052, Victoria, Australia. E-
mail address for H.K. Graham: [email protected] doi:10.2106/JBJS.E.00993

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